{"id":16,"title":"PRIVATE CAR POLICY- BUNDLED CLAIM FORM","purpose":"claim","insurer":{"slug":"acko-life-insurance","name":"Acko Life Insurance Limited"},"source_pdf":"https://acko-cms.ackoassets.com/Claim_Form_Private_Car_Policy_Bundled_d3f9807c96.pdf","sha256":"fc5152adffca49a55b80c365f910491b11875ac95b01b258562031de6741467b","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim insurance for damages or theft related to their private car policy. The insured fills this form to provide details of the accident, loss, vehicle, driver, and third party information.","notes":["Fill the form in CAPITAL LETTERS and sign it.","Do not leave any column unanswered; write 'N/A' if not applicable.","If information is not readily available, send the form immediately and provide missing details later.","Use original documents for verification where specified.","Attach original blank cancelled cheque and PAN card copy for electronic fund transfer.","The form includes sections for accident claims, theft claims, and third party details.","The form is not an admission of liability by the insurer."],"title":"PRIVATE CAR POLICY- BUNDLED CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. Details Of Insured / Claimant","fields":[{"help":"Enter your insurance policy number","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"Claim Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end date of insurance period","type":"date","label":"Period of Insurance: To","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insured person","type":"text","label":"Name of the Insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pincode","type":"number","label":"Pincode:","options":[],"required":null,"pdf_field":""},{"help":"Enter telephone STD code","type":"number","label":"STD code:","options":[],"required":null,"pdf_field":""},{"help":"Enter landline phone number","type":"phone","label":"Phone Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. Details Of Loss / Damage / Accident / Theft","fields":[{"help":"Date of accident or theft","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Time of accident or theft with AM/PM","type":"text","label":"Time:","options":["A.M","P.M."],"required":null,"pdf_field":""},{"help":"Location where accident or theft occurred","type":"text","label":"Location:","options":[],"required":null,"pdf_field":""},{"help":"City of accident or theft","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of accident or theft","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Pincode of accident or theft location","type":"number","label":"Pincode:","options":[],"required":null,"pdf_field":""},{"help":"Select the type of road where accident occurred","type":"choice","label":"Road Type:","options":["Express Way","Hill Road","National / State Highway","City / Town Road","District Road","Other"],"required":null,"pdf_field":""},{"help":"Enter speed in kmph","type":"number","label":"Speed at the time of acident","options":[],"required":null,"pdf_field":""},{"help":"Select type of loss and specify if partial theft","type":"choice","label":"Type of Loss:","options":["Own Damage","Theft","Partial Theft","specify"],"required":null,"pdf_field":""},{"help":"Describe the vehicle usage purpose","type":"text","label":"Purpose for which the vehicle was being used at the time of accident / Theft","options":[],"required":null,"pdf_field":""},{"help":"Enter number of persons in vehicle","type":"number","label":"Number of persons travelling:","options":[],"required":null,"pdf_field":""},{"help":"Provide details if other vehicle involved","type":"text","label":"Any other vehicle involved","options":[],"required":null,"pdf_field":""},{"help":"Name of person who had keys at theft time","type":"text","label":"In case of theft, keys in the possession of?","options":[],"required":null,"pdf_field":""},{"help":"Name of key holder","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Phone number of key holder","type":"phone","label":"Phone Number:","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of key holder","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""},{"help":"Name and contact details of witnesses or persons at accident location","type":"text","label":"Contact Details of person/s at the Location","options":[],"required":null,"pdf_field":""},{"help":"Name of contact person at location","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Relationship of contact person to insured","type":"text","label":"Relationship with Insured","options":[],"required":null,"pdf_field":""},{"help":"Phone number of contact person","type":"phone","label":"Phone Number:","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of contact person","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""},{"help":"Email of contact person","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Describe how the accident or loss happened","type":"text","label":"Describe cause of Loss / Damage / Accident:","options":[],"required":null,"pdf_field":""},{"help":"Draw and describe accident spot and vehicle position","type":"text","label":"Please draw a sketch of spot of accident & describe position of vehicle at the time of accident, including nearby landmarks","options":[],"required":null,"pdf_field":""},{"help":"Indicate if FIR or DDR or GDR was filed","type":"yes-no","label":"FIR / DDR / GDR if any:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Explain reasons if FIR/DDR/GDR not filed","type":"text","label":"If not (reasons)","options":[],"required":null,"pdf_field":""},{"help":"Enter FIR or GDR or DDR number","type":"text","label":"Police FIR / GDR / DDR Details No.:","options":[],"required":null,"pdf_field":""},{"help":"Date of FIR/GDR/DDR","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Name of police station where FIR/GDR/DDR filed","type":"text","label":"Police Station Name:","options":[],"required":null,"pdf_field":""},{"help":"Date related to police station entry","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"City of police station","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of police station","type":"text","label":"State:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. Garage Details","fields":[{"help":"Name of garage where vehicle is repaired","type":"text","label":"Garage Name:","options":[],"required":null,"pdf_field":""},{"help":"Address of garage","type":"text","label":"Garage Address:","options":[],"required":null,"pdf_field":""},{"help":"Name of contact person at garage","type":"text","label":"Garage Contact Person Name:","options":[],"required":null,"pdf_field":""},{"help":"Time when claim form submitted to garage","type":"text","label":"Time of submission:","options":["A.M","P.M."],"required":null,"pdf_field":""},{"help":"Date when claim form submitted to garage","type":"date","label":"Date of submission:","options":[],"required":null,"pdf_field":""},{"help":"Phone number of garage","type":"phone","label":"Garage Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Email of garage","type":"email","label":"Garage Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. Vehicle Details","fields":[{"help":"Vehicle registration number","type":"text","label":"Reg. No.:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle manufacturer","type":"text","label":"Make:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle model","type":"text","label":"Model:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle chassis number","type":"text","label":"Chassis No.:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle engine number","type":"text","label":"Engine No.:","options":[],"required":null,"pdf_field":""},{"help":"Current odometer reading","type":"number","label":"Odometer Reading:","options":[],"required":null,"pdf_field":""},{"help":"Vehicle color","type":"text","label":"Colour:","options":[],"required":null,"pdf_field":""},{"help":"Date vehicle was registered","type":"date","label":"Date of Registration:","options":[],"required":null,"pdf_field":""},{"help":"RTO jurisdiction of vehicle registration","type":"text","label":"RTO Jurisdiction:","options":[],"required":null,"pdf_field":""},{"help":"Select vehicle class","type":"choice","label":"Vehicle Class:","options":["Two wheeler","Private car","Others (specify)"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. Driver Details","fields":[{"help":"Full name of driver at time of accident","type":"text","label":"Name of Driver:","options":[],"required":null,"pdf_field":""},{"help":"Driver's date of birth","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Relationship of driver to insured","type":"text","label":"Relationship with Insured:","options":[],"required":null,"pdf_field":""},{"help":"Select driver's gender","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Select driver's education qualification","type":"choice","label":"Qualification:","options":["Below 10th Std.","10th Pass","12th Pass","Graduation","PG"],"required":null,"pdf_field":""},{"help":"Driver's telephone STD code","type":"number","label":"STD code:","options":[],"required":null,"pdf_field":""},{"help":"Driver's phone number","type":"phone","label":"Phone Number:","options":[],"required":null,"pdf_field":""},{"help":"Driver's mobile number","type":"phone","label":"Mobile:","options":[],"required":null,"pdf_field":""},{"help":"Driver's email address","type":"email","label":"E-mail ID:","options":[],"required":null,"pdf_field":""},{"help":"Driver's license number","type":"text","label":"Driving License No.:","options":[],"required":null,"pdf_field":""},{"help":"License issue date","type":"date","label":"Date of Issue:","options":[],"required":null,"pdf_field":""},{"help":"License expiry date","type":"date","label":"Date of Expiry:","options":[],"required":null,"pdf_field":""},{"help":"RTO that issued the license","type":"text","label":"Issuing RTO:","options":[],"required":null,"pdf_field":""},{"help":"Select license type and class","type":"choice","label":"Type of License:","options":["Class: M-Cycle W/G","M-Cycle Wo/G","LMV","Transport","Non-Transport","HGV","Passenger","Permanent","Temporary"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. Third Party Death / Injury / Personal Accident Details","fields":[{"help":"Serial number for each person","type":"number","label":"SI No.","options":[],"required":null,"pdf_field":""},{"help":"Name of third party or injured person","type":"text","label":"Name of person","options":[],"required":null,"pdf_field":""},{"help":"Indicate if person was third party passenger","type":"yes-no","label":"Whether TP passenger","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Address of the person","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Contact number of the person","type":"phone","label":"Contact No.","options":[],"required":null,"pdf_field":""},{"help":"Specify death or injury type","type":"text","label":"Death / Type of Injury","options":[],"required":null,"pdf_field":""},{"help":"Hospital name if admitted","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Doctor attending the person","type":"text","label":"Name of Attending Doctor","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any legal notices","type":"text","label":"Details of any legal/Court Notice received","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Place where form is signed","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Signature of insured or claimant","type":"signature","label":"Signature:","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Print name of insured or claimant","type":"text","label":"Name of Insured / Claimant:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Bank Details for Electronic Fund Transfer","fields":[{"help":"Select yes to provide bank details for payment","type":"yes-no","label":"Would you like to opt for Electronic Fund Transfer as mode of payment?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of account holder as per bank","type":"text","label":"Payee Name (as per bank records):","options":[],"required":null,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Payee Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Type of Account:","options":["Saving","Current","Other"],"required":null,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch name","type":"text","label":"Branch Name:","options":[],"required":null,"pdf_field":""},{"help":"Bank branch address","type":"text","label":"Address of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"Bank MICR code","type":"text","label":"MICR Code No. of the Bank:","options":[],"required":null,"pdf_field":""},{"help":"PAN number of payee","type":"text","label":"Permanent Account Number (PAN) of Payee:","options":[],"required":null,"pdf_field":""},{"help":"Signature for bank mandate","type":"signature","label":"Signature of the Account Holder (Insured)","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Private car insurance claims including own damage, theft, partial theft, third party death/injury, and personal accident claims","attachments":["Proof of insurance - Policy / Cover Note copy","Copy of Registration Book, Tax Receipt (Please furnish original for verification)","Copy of Motor Driving License of the person driving the vehicle at the time of accident (Please furnish original for verification)","Police Panchanama / FIR","Estimate of repairs from the repairer where the vehicle is to be repaired","Repair Bills / Invoices and payment receipts after the job is completed","Discharge Voucher","ID Proof (Passport, Driving license, Voter ID, PAN card, Aadhaar card)","Address proof (Passport, Driving license, Voter ID, Aadhaar card)","Original Policy document (for theft claims)","Original Registration Book / Certificate and Tax Payment Receipt (for theft claims)","All the sets of keys / Service Booklet / Warranty Card / Original Purchase Invoice (for theft claims)","Police Panchanama / FIR and Final Report / Non Traceable Report (for theft claims)","Acknowledged copy of letter addressed to RTO intimating theft and informing “NON-USE” (for theft claims)","Form 28, 29 and 30 signed by the insured and Form 35 signed by the Financier (for theft claims)","Subrogation cum special Power of Attorney (for theft claims)","Consent towards agreed claim settlement value from yourself and Financer (for theft claims)","NOC from the Financer if claim is to be settled in your favour (for theft claims)","Indemnity bond & discharge voucher (for theft claims)","Original blank cancelled cheque signed by the Payee (for EFT)","PAN CARD copy of Payee (for EFT)"],"declarations":["The insured warrants the truth of all statements and understands that false or fraudulent statements may forfeit the claim and policy.","The insured has attached the required documents and understands that delays may occur if requirements are not met.","The insured agrees to provide additional information or documentation if required.","The insured authorizes the company to access information relevant to the claim.","Submission of documents or bank details does not imply admission of liability by the company.","The customer agrees to indemnify the company against any claims or losses arising from RTGS/NEFT payment facility.","The customer understands the terms and conditions of RTGS/NEFT payments and agrees to them.","The customer may terminate RTGS/NEFT facility with 15 days prior written notice to the company.","The company may amend terms and conditions with prior notice where feasible.","Notices may be given by hand, email, website, or post to the customer's last address.","These terms are governed by Indian law and disputes will be settled in Mumbai courts."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102","label":"Claims postal address","level":null,"hours":null,"applies_to":"life","source_url":"https://acko-cms.ackoassets.com/2_Acko_Life_Group_Term_Protect_Micro_Insurance_Master_Policy_Document_ca9093f4de.pdf","quote":"at claims.life@acko.com or by sending the documents to the address mentioned below or any other office of the Company:\nClaims Department, ACKO LIFE INSURANCE LIMITED., 36/5, Hustle Hub One East, Somasandrapalya, 27th Main Road, Sector 2, HSR Layout, Somasandrapalya HSR 2nd Sector Bus Stop, Bengaluru, Bengaluru Urban, Karnataka, 560102\n\nAny person claiming the Death Benefit under this Policy can download the claim request documents from Our website www.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-210-1992","label":"Claims phone number","level":null,"hours":"9:00 AM – 8:00 PM","applies_to":"life","source_url":"https://www.acko.com/life/claims/","quote":"t us\nSupport\nRenewals\nNew to ACKO?\nRenew life insurance\nExisting ACKO Customer\nLogin and renew policy\nClaims\nCall us at\n1800-210-1992\nEmail us at\n[email protected]\nLogin\nACKO Life Home\n/\nACKO Life Insurance Claims Process\nGroup Claims Process\nClaims Pro","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/acko-life-insurance/16-private-car-policy-bundled-claim-form"}